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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 07/18/2025
Date Signed: 07/18/2025 01:44:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2025 and conducted by Evaluator Angelica Boyles
COMPLAINT CONTROL NUMBER: 08-AS-20250505153041
FACILITY NAME:MONTERA, THEFACILITY NUMBER:
374604083
ADMINISTRATOR:EMILY TURNERFACILITY TYPE:
740
ADDRESS:5740 LAKE MURRAY BLVDTELEPHONE:
(619) 832-2599
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:225CENSUS: 180DATE:
07/18/2025
UNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Aileen Spence Associate Executive DirectorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Licensee retained a resident with incompatible needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to deliver investigative findings regarding the above mentioned allegation. LPA identified herself, explained the purpose of the visit and nature of the complaint to Aileen Spence, Associate Executive Director.

On May 5, 2025 the Department received this complaint which alleged licensee retained a resident, Resident #1 (R1), with incompatible needs. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] The Department’s investigation included a facility tour, record reviews, as well as interviews with residents and staff.

(Continued on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Angelica Boyles
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2025 and conducted by Evaluator Angelica Boyles
COMPLAINT CONTROL NUMBER: 08-AS-20250505153041

FACILITY NAME:MONTERA, THEFACILITY NUMBER:
374604083
ADMINISTRATOR:EMILY TURNERFACILITY TYPE:
740
ADDRESS:5740 LAKE MURRAY BLVDTELEPHONE:
(619) 832-2599
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:225CENSUS: 180DATE:
07/18/2025
UNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Aileen Spence Associate Executive DirectorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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9
Licensee’s staff did not provide timely incontinence care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to deliver investigative findings regarding the above mentioned allegation. LPA identified herself, explained the purpose of the visit and nature of the complaint to Aileen Spence Associate, Executive Director.

On May 5, 2025 the Department received this complaint which alleged licensee’s staff did not provide timely incontinence care to Resident #1 (R1). [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] The Department’s investigation included a facility tour, record reviews, as well as interviews with residents and staff.

(Continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Angelica Boyles
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20250505153041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MONTERA, THE
FACILITY NUMBER: 374604083
VISIT DATE: 07/18/2025
NARRATIVE
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(Continued from LIC9099)

Interviews with various staff corroborated that while the extent of toileting assistance may vary per resident’s specific care plan, checks are done every two hours for residents who need toileting assistance. Regarding R1 specifically, staff interviews reported that R1 does not have incontinence, but per care notes, is supposed to receive assistance in toileting 3 times per shift. Records reviewed showed that R1 does not have bowel/bladder impairments and their capacity for self care is needing moderate assistance in caring for their own toileting needs.

Staff interviews revealed that R1 does not usually utilize the call pendant to ask for assistance and will toilet herself. All interviews indicate R1 tries to maintain her independence and will refuse assistance when staff show up to follow the care notes. LPA interviewed R1 who stated that they are able to toilet themselves without assistance most of the time. R1 reported no concerns in receiving timely care from staff regarding any issue, including incontinence/toileting. R1 reported that they will occasionally call for assistance in toileting and will receive staff help promptly.LPA observations of residents did not raise any concerns regarding incontinence care needs being unmet.

The Department has investigated the allegation licensee’s staff did not provide timely incontinence care. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated.

An exit interview was conducted with Aileen Spence Associate Executive Director, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Angelica Boyles
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20250505153041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MONTERA, THE
FACILITY NUMBER: 374604083
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2025
Section Cited
CCR
87466
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Observation of the Resident: "The licensee shall ensure that residents are regularly observed for changes... When changes are observed, the licensee shall ensure that such changes are documented..."
This requirement was not met as evidenced by:
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Associate Executive Director agreed to get an updated and signed Physician's Report and Needs and Service Plan reflecting R1's change in condition. Associate Executive Director agreed to email LPA a copy of updated documents by POC due date.
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Based on records reviewed, staff interviews, and LPA observations, 1 of 180 residents (R1) had a change of a physical health condition which staff observed, but Licensee did not ensure that this change was documented. This posed a potential health risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Angelica Boyles
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20250505153041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MONTERA, THE
FACILITY NUMBER: 374604083
VISIT DATE: 07/18/2025
NARRATIVE
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(Continued from LIC9099)

Per R1’s most recent Physician’s Report for Residential Care Facilities for the Elderly (LIC602A), R1 is deemed ambulatory. However, this is inconsistent with LPA observations, staff interviews, and records reviewed. During an unannounced facility visit, LPA observed R1 being pushed in a wheelchair. Interviews with staff caregivers unanimously corroborated that they do not believe R1 to be ambulatory because R1 needs assistance in exiting the facility. Per the 602A, the definition of nonambulatory is “a person who is unable to leave a building unassisted under emergency conditions…and/or a person who depend upon mechanical aids such as crutches, walkers, and wheelchairs.” Additional records reviewed revealed that R1 required lift assist from the fire department on three occasions because staff were unable to assist R1. It was reported that on one occasion it took four staff to assist R1 from the ground. The most recent Resident Assessment dated 6/17/25 noted R1 requiring “1 person total assist or wheelchair escort to and from activities, meals, etc.” but this document is unsigned by facility staff and R1.

The Department has investigated the allegation that licensee retained a resident with incompatible needs. Based upon the information obtained during this investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. This deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached 9099D.

An exit interview was conducted with Aileen Spence, Associate Executive Director to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Angelica Boyles
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5